Individual
DR. MARY ELLEN BRODERICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PH.D.
Contact information
Practice address
2902 MADISON ST, MARIANNA, FL 32446-3450
(850) 482-8830
Mailing address
1126 STILLWATER DR, DELAND, FL 32720-2571
(386) 734-5852
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
PY 3181
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
75290
BCBS PSYCHOLOGIST
FL
Enumeration date
02/14/2007
Last updated
07/08/2007
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